What does gastroscopy show after normal cytosponge in patients with reflux symptoms? A 2 year prospective series

Introduction

We established an early diagnosis Cytosponge service for patients routinely referred with reflux symptoms to aid early diagnosis, management and triage to gastroscopy. As Cytosponge samples the cardia and oesophagus only, distal pathology may not be detected without further investigation. This study evaluates the findings at gastroscopy in those with negative Cytosponge and persistent symptoms in a single site UK hospital who have 2 years of experience using Cytosponge.

Methods

Between November 2020 and January 2023, all patients routinely referred to the clinical service with reflux and heartburn symptoms were assessed promptly in a nurse-run clinic and offered Cytosponge as a first test. We excluded patients with known Barrett’s, cancer, fundoplication and strictures. Patients found to be trefoil factor 3 (TFF3) +ve, a marker for intestinal metaplasia (IM), had routine gastroscopy. Patients with atypia and/or p53+ve (markers for dysplasia) had urgent gastroscopy. Patients with other significant findings or persistent symptoms were offered investigation as appropriate. All patients were given lifestyle and management advice and were followed up by nurse-led telephone clinic <6 weeks. Where symptoms persisted a gastroscopy was requested.

Results

482 patients had successful Cytosponge procedures with adequate sampling. There were no adverse effects. 59 patients (12%) had positive or equivocal TFF3. 5 (1%) patients had high risk biomarkers on Cytosponge, endoscopy showing 1 high grade dysplasia, 1 indefinite for dysplasia and 1 intramucosal cancer. 27 patients had confirmed Barrett’s- overall 5.6% new Barrett’s diagnoses. 423 (88%) had negative Cytosponge. Due to persistent symptoms 81 (19%) patients were referred for gastroscopy finding: Normal 56, pending 5, gastric cancer 1 (diagnosed within 2w of Cytosponge) gastritis 8, hiatus hernia 5, oesophagitis 4,Duodenal ulcer 1, portal gastropathy 1. 342 patients avoided gastroscopy.

Conclusions

We report encouraging outcomes from the largest English site using Cytosponge in triaging routine reflux patients in secondary care who would otherwise be awaiting gastroscopy. Cytosponge has led to prompt diagnosis of new non-dysplastic Barrett’s and oesophageal dysplasia. In those with a negative Cytosponge and ongoing symptoms, gastroscopy promptly identified 1cancer and benign abnormalities. By reducing pressures on the endoscopy service Cytosponge triage enabled timely gastroscopy in those who require and aided decision making in a pandemic environment with limited resources. Unnecessary gastroscopy has reduced with subsequent environmental benefit. Longer term evaluation and cost-effectiveness on a National scale is in progress